II. Epidemiology
-
Major Depression
Incidence has increased in the last decade
- 2005: Major Depression episode in last year occurred in 9%
- 2014: Major Depression episode in last year occurred in 11%
- 2016: Major Depression episode in last year occurred in 13%
- From 5% in 12 year olds to 17% in 17 year olds
- Gender predominance
- Boys are slightly more likely than girls to have Major Depression before age 12 years old
- Girls are up to twice as likely as boys to experience Major Depression after Puberty
III. Precautions
- Missed or incorrect diagnosis occurs in up to 70%
-
Major Depression is treated in only 40% of cases that effect children and teens
- Despite 70% experiencing significant Impairment from their Major Depression
- Pitfalls in diagnosis
- See Major Depression Differential Diagnosis
- Atypical presentations: Headaches, Stomache pain
- Downplayed symptoms if parents are also depressed
IV. Risk factors
- Comorbid illness (e.g. Diabetes Mellitus, Asthma)
- Puberty-related hormonal changes (esp. early Puberty)
- Family History of Major Depression
- Medications: Accutane
- Tobacco Abuse or Marijuana use
- Attention Deficit Disorder
- High functioning Autism
- LGBTQ
- Obesity
- Emotional stressors or social factors
- Poor family functioning or parental rejection
- Relationship break-ups or loss of loved one
- Video game addiction
- Social Media problematic use
- Decreased parent and peer attachment
- Victim of Bullying, Violence, physical, sexual or emotional abuse (see Child Abuse)
- Inadequate Physical Activity
- Natural disasters
V. Screening
- See Depression Screening Tools
- USPTF, AAFP and AAP all recommend Major Depression screening in age 12-18 years
- Ages 7 to 17 years old
- Ages 8 to 12 years old
- Reynolds Child Depression Scale
- Ages 13 to 18 years old
- Reynolds Adolescent Depression Scale
- Ages 13 and older
- Ages 14 and older
VI. Diagnosis
- See Major Depression Diagnosis
- See Major Depression for symptoms
VII. Differential Diagnosis
- See Major Depression Differential Diagnosis
- Pediatric Bipolar Disorder
- Presents with irritability, sadness and Insomnia (euphoria is typically absent)
- Persistent Depressive Disorder (Dysthymia)
- Depressed mood for more days than no depressed mood for at least one year
- Disruptive mood dysregulation
- Persistently angry with temper outbursts
- Post-Traumatic Stress Disorder may present in similar fashion
- Other associated conditions
- Eating Disorder
- Conduct Disorder
- Anxiety Disorder (comorbid with Major Depression in up to 74% of cases)
- Behavioral disorders (comorbid with Major Depression in up to 47% of cases)
VIII. Management: Psychotherapy
- Cognitive behavior therapy (CBT, 12-24 sessions of behavioral activation techniques)
- Coping skill improvement
- Communication skill improvement
- Peer relationship improvement
- Problem solving techniques
- Negative thinking pattern resolution
- Emotional regulation
- Interpersonal therapy (IPT, limited to adolescents and older)
- Adaptation to relationship changes
- Personal role transitions
- Interpersonal relationship building
- Therapy Plan with Goal Examples
- Treat others with respect
- Eat family meals
- Maintain school work
- Spend time with peers in activities
- Safety Plan
- Limit access to lethal Suicide methods (e.g. firearms)
- References
IX. Management: Medications
- Background
- Medications are best combined with psychotherapy
- Psychosocial underlying factors respond best to therapy
- Trauma
- Divorce or separation
- Relationship break-ups
- Academic pressures
- Indications
- Moderate to severe depression
- Current depression with a prior episode
- Especially if treated with Antidepressants with the last episode
- Family History of depression
- Especially if significant response to medications in that family member
- Mood refractory to non-medication measures
- Refractory to modifications in environmental stressors
- Refractory to psychotherapy
- References
- Protocol
- Initial clinic visit
- Medication started
- Education of parents and patient
- Risks and benefits (see below)
- Common adverse effects of SSRIs and the delay in benefit for at leats 3-4 weeks
- Do not abrupty stop the SSRI (risk of Antidepressant Withdrawal)
- Warning signs to immediately seek medical attention
- Worsening depression
- Unusual behavior
- Suicidality
- Frequent phone calls (or clinic visits) after starting medication
- Schedule
- Every week for 4 weeks, then
- Every 2 weeks for 4 weeks
- Assess interim history
- Assess mood
- Assess for Suicidality
- Assess for Agitation, Insomnia, impulsivity (associated with Suicidality)
- Assess medication adverse effects
- Gastrointestinal adverse effects
- Nervousness
- Headache
- Motor restlessness
- Schedule
- Follow-up clinic visits
- Schedule (in addition to phone follow-up above)
- One month after starting medication
- Three months after starting medication
- Assess interim history
- Assess mood, Suicidality and adverse effects as above
- Titrate medication dose to effect
- Schedule (in addition to phone follow-up above)
- Medication course
- Treat for at least 6 months after depression remission
- Initial clinic visit
-
Selective Serotonin Reuptake Inhibitors
- All Antidepressants have an FDA black box warning regarding Suicidality risk in children
- Number Needed to Treat with SSRI for benefit in 1 child: 10
- Number needed to harm with SSRI for Suicidality in 1 child: 112
- Risk of Suicidality in children on Antidepressants is 0.7% higher than Placebo
- Preferred SSRIs that are FDA approved
- Fluoxetine (Prozac)
- SSRI most consistently found effective in Childhood Depression and FDA approved
- Start at 10 mg and titrate at follow-up visit in 2 weeks
- Escitalopram (Lexapro)
- FDA approved for age 12 years and older
- Fluoxetine (Prozac)
- Other SSRIs that are well tolerated and have some evidence of benefit
- All Antidepressants have an FDA black box warning regarding Suicidality risk in children
-
Bupropion
- Consider for ages 12 to 20 years old with Major Depression
- Also consider for weight loss, Tobacco Cessation, Attention Deficit Disorder
- Effective in adolescent Major Depression with decreased hospitalizations and improved Medication Compliance
- Avoid in Seizure Disorder, Eating Disorder and Suicidality
- Gensel (2024) Am Fam Physician 110(1):77-8 [PubMed]
- Consider for ages 12 to 20 years old with Major Depression
- Other Antidepressants that are not recommended
- Paroxetine is NOT recommended in children due to increased Suicidality, adverse effects (per FDA)
- Tricyclic Antidepressants appear ineffective
- Venlafaxine has less evidence to support use, and may have increased risk of Suicidality
- No evidence supporting MAO Inhibitors
- References
- (2014) Presc Lett 21(1): 5
X. Management: Psychiatry referral indications
- Symptoms refractory to first-line medications despite titration of dose
- Children with depression under age 11 years old
- Chronic depression
- Comorbid Substance Abuse
- Suicidality (especially if a Suicide plan)
- Parental engagement lacking
XI. Complications
-
Suicide
- See Suicide Screening
- See Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
- Seriously considered in 20% of teens
- Attempted Suicide in 8% of teens
- Growth Delay or Developmental Delay
- Impaired learning
- Persistent depression into adulthood (2-4 fold risk)
XII. Resources
- Patient Information: APA Guide to Medications in Children and Adolescents
-
Suicide Prevention Lifeline
- Phone: (800) 273-TALK
- Crisis Text Line
- Text "HOME" to 741741